Provider Demographics
NPI:1750511408
Name:YOUNG, SHANNON KELLIM (LP, LCSW)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KELLIM
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LP, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 HILYARD ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4311
Mailing Address - Country:US
Mailing Address - Phone:541-255-8255
Mailing Address - Fax:
Practice Address - Street 1:1461 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4311
Practice Address - Country:US
Practice Address - Phone:541-255-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR44541041C0700X
OR2298103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical